985172

research-article2021
SJP0010.1177/1403494820985172K. E. Telle et al.Risk factors for COVID-19 hospitalizations in Norway

Scandinavian Journal of Public Health, 2021; 49: 41–47

Original Article

Factors associated with hospitalization, invasive mechanical

ventilation treatment and death among all confirmed
COVID-19 cases in Norway: Prospective cohort study

KJETIL E. TELLE , MARI GRØSLAND, JON HELGELAND & SIRI E. HÅBERG

Norwegian Institute of Public Health, Oslo, Norway

Abstract
Aims: For everyone with a positive test for SARS-CoV-2 in Norway, we studied whether age, sex, comorbidity, continent of
birth and nursing home residency were risk factors for hospitalization, invasive mechanical ventilation treatment and death.
Methods: Data for everyone who had tested positive for SARS-CoV-2 in Norway by end of June 2020 (N = 8569) were
linked at the individual level to hospitalization, receipt of invasive mechanical ventilation treatment and death measured
to end of July 2020. Underlying comorbidity was proxied by hospital-based in- or outpatient treatment during the two
months before the SARS-CoV-2 test. Multivariable generalized linear models were used to assess risk ratios (RRs). Results:
Risk of hospitalization was particularly high for elderly (for those aged 90 and above: RR 9.5; 95% confidence interval (CI)
7.1–12.7; comparison group aged below 50), Norwegian residents born in Asia, Africa or Latin-America (RR 2.1; 95% CI
1.9–2.4; comparison group born in Norway), patients with underlying comorbidity (RR 1.6; 95% CI 1.4–1.8) and men
(RR 1.3; 95% CI 1.2–1.5). Men and residents born in Africa, Asia and Latin-America were also at higher risk of receiving
ventilation treatment and dying, but the mortality risk was especially high for the elderly (for those aged 90 and above: RR
607.9; 95% CI 145.5–2540.1; comparison group aged below 50) and residents in nursing homes (RR 4.2; 95% CI 3.1–5.7).
Conclusions: High age was the most important predictor of severe disease and death if infected with SARS-
CoV-2, and nursing home residents were at particularly high risk of death.

Keywords: COVID-19, risk factors, quality of health care, epidemics, SARS virus, SARS-CoV-2, health services research

Background people with white ethnicity [2]. Underlying comor-

bidity is associated with severe disease, but the spe-
Maintaining adequate health care services during the cific conditions that predict mortality varies across
COVID-19-pandemic – both for patients with studies [1]. The need for more in-depth epidemio-
COVID-19 and for all other inhabitants – is a core logical analyses of severe outcomes of COVID-19
goal for the health authorities at national, regional remain important to increase our ability to handle
and local levels. To do so, it is essential with knowl- the pandemic. We look at the more serious outcomes
edge about who among those infected with SARS- – hospitalization, need for invasive mechanical venti-
CoV-2, the virus causing COVID-19, will need lation treatment and death – and consider to what
intensive health care. extent particularly frail patients in nursing homes are
Previous studies have found a strong correlation transferred to intensive hospital care when develop-
between age and death from COVID-19, and that ing COVID-19.
men are more at risk for severe disease than women Reports suggest that in several countries, a large
[1–3]. Results for ethnic groups are more mixed [1– proportion – or even the majority – of deaths related
4], though in a large study from the UK, Blacks and to COVID-19 occur in nursing homes [5,6]. In
South Asian people were at higher risk of death than Norway, for example, up to 60 percent of the 251

Correspondence: Kjetil E. Telle, Norwegian Institute of Public Health, Box 222 Skoyen, 0213 Oslo, Norway. E-mail: KjetilElias.Telle@fhi.no

Date received 20 August 2020; reviewed 13 October 2020; 14 November 2020; accepted 9 December 2020

© Author(s) 2021
Article reuse guidelines: sagepub.com/journals-permissions
DOI: 10.1177/1403494820985172
https://doi.org/10.1177/1403494820985172
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42    K. E. Telle et al.
persons with COVID-19 who had died by July 7,
2020, died in nursing homes [6]. This may suggest
that many patients with the most severe infections are
considered too frail to benefit from intensive hospital
treatment. This knowledge will have effects on the
capacity necessary for intensive hospital treatment.
The Norwegian health care system is almost exclu-
sively publicly funded, and every resident has the same
access to the high-quality services. The out-of-pocket
fees are low by Norwegian standards – about €25 for
consulting a general practitioner, from whom a refer-
ral is necessary to access non-acute specialist care,
which is free. Necessary drugs are also covered by the
public funding with no or limited out-of-pocket fees.
Like all residents, immigrants, who comprise 15 per-
cent of the 5.4 million Norwegians, have the same
access to the universal health care system, though
there are some indications that utilization differs
across immigrants and Norwegian-born residents [7].
Aims
To improve health care authorities’ ability to allocate
resources adequately during the pandemic, we
wanted to provide nationally representative informa-
tion about the characteristics of all inhabitants with
confirmed COVID-19 who needed hospital treat-
ment, invasive mechanical ventilation treatment or
who died.
For everyone with a positive test for SARS-CoV-2
in Norway, we studied whether age, sex, comorbidity,
continent of birth and nursing home residency were
risk factors for hospitalization, invasive mechanical
ventilation treatment and death. In line with previous
studies, we expected a positive association between
severe COVID-19 and age, male sex and comorbidi-
ties [1–3]. Previous studies did not allow us to hold
similarly clear expectations for continent of birth and
nursing home residency, though there did exist
reports of many infections, hospitalizations and
deaths in these groups [5,6]. In particular, given
these reports and the frailty of nursing home resi-
dents in Norway, we expected such residents to be at
high risk of severe disease and death [6,8].
Methods
As part of the legally mandated responsibilities of the
Norwegian Institute of Public Health (NIPH) during
epidemics, a new emergency preparedness register cov-
ering the entire Norwegian population was established
in April 2020 [9]. In cooperation with the Norwegian
Directorate of Health and the Norwegian Intensive
Care and Pandemic Register, individual-level data from
several electronic administrative sources from January
1, 2020, was compiled and linked at the individual level
using the unique personal identification number pro-
vided to everyone in Norway at birth or upon immigra-
tion. The purpose of the preparedness register is to
provide rapid overview and knowledge of how the pan-
demic and the measures that are implemented to con-
tain the spread of the virus, affect the population’s
health, use of health care services and health-related
behaviors. The register contains daily updated informa-
tion from the Norwegian Surveillance System for
Communicable Diseases (MSIS), which has existed for
many years. New cases that tested positive for SARS-
CoV-2 in a polymerase chain reaction (PCR) test, are
legally subject to notification to MSIS without delay.
The laboratory conducting the test and the medical
doctor diagnosing the patients are informing MSIS
about the case. Data are then transferred from MSIS to
the preparedness register every morning. The prepared-
ness register also contains daily updated information
from the administrative record systems of all hospitals
in Norway. Every night, information is copied from the
hospital records and sent to the Norwegian Directorate
of Health, and then transferred to the preparedness reg-
ister in the morning. We used data from the prepared-
ness register for this analysis.
Our study population included everyone who had
tested positive for SARS-CoV-2 in Norway up to
June 30, 2020 (8569). The dataset included dates
(from January 1, 2020) of first positive test for SARS-
CoV-2, hospital admissions, entries onto invasive
mechanical ventilation treatment, discharges and
death (both inside and outside hospital), as well as
sex, age and country of birth, and information on
nursing home residency at time of test for COVID-
19. To proxy for underlying comorbidity, we con-
structed a binary variable that indicated if the person
had been hospitalized (inpatient) or had received
care in a hospital-based clinic (outpatient) at least
once during the two months before the test. It is well
established that hospitalization is highly correlated
with multimorbidity [10,11].
We studied three outcomes: 1) hospitalized (inpa-
tient) two days before through 14 days after the posi-
tive test; 2) invasive ventilator treatment during this
hospitalization; and 3) death within 30 days after the
positive test. We measured the outcomes through
July 2020.
For each of the three dichotomous outcomes, a
multivariable generalized linear model with log link,
Poisson distribution and robust standard errors
[12,13] was used to assess associations with sex, age
(in age groups <50, 50–60, 60–70, 70–80, 80–90,
⩾90 years), place of birth (in the four groups
Norway; rest of Europe, North-America or Oceania;
Africa, Asia or South America; Unknown), the proxy
 Risk factors for COVID-19 hospitalizations in Norway   43
Figure 1. New cases with confirmed SARS-CoV-2 per day in
Norway, and number of them admitted to hospital, entering inva-
sive mechanical ventilation treatment and dying per day. Seven-
day moving averages.
Note: total number of individuals in Norway with confirmed
SARS-CoV-2 infection by June 30, 2020 (N = 8569). Every
individual is recorded the first time that the person was registered
infected, hospitalized, entering invasive mechanical ventilation
treatment and dying. The peak for number of new cases was on
March 24, with 313 cases; for number of new hospitalizations on
March 25, with 64 cases; for number of new entries onto invasive
mechanical ventilation treatment on March 25, with 16 cases; and
for deaths on April 6, with 13 cases.
variable for comorbidity and nursing home resi-
dency. Given the data available to us, variables were
chosen and operationalized to align with previous
studies [1–4]. Nursing home residency was included
to enable the analysis of transfers from nursing
homes to hospital treatments and of mortality for
this particularly frail group [5,6]. Alternative models
were run to ensure that the choice of specific age
groups did not substantively affect the results. In
particular, to make sure that the result on mortality
of nursing home residents was not an artifact of the
underlying age structure, we checked (results avail-
able in Supplemental Tables A1 and A2) that the
estimate remained similar when restricting the sam-
ple to those above 80 years of age and when control-
ling for age linearly. Analyses with categorical
variables for separate countries of birth in Asia and
Africa with more than 100 cases was also under-
taken (results available in Supplemental Table A3),
but only results for aggregate continent groups are
referred to in the main text since estimates for
smaller groups were typically statistically indistin-
guishable. Results from models run separately on
each of the continent of birth groups are also avail-
able in the Supplemental Table A4. Data handling
and analyses were performed in Stata version 16.1
(StataCorp).
Institutional board review was conducted, and the
Ethics Committee of South-East Norway confirmed
(June 4, 2020, #153204) that external ethical board
review was not required.
Results
In Norway, the first confirmed case with COVID-19
occurred in late February, and the number of new
cases peaked on March 24, with 313 new cases. While
the magnitude is lower for the subgroup who were
hospitalized, and especially for the subgroup who
received invasive mechanical ventilation treatment,
the curves peaked at about the same time (March 24
and 25, with 64 and 16 cases, respectively). For the
small subgroup who died, the peak is less pronounced
and occurs a couple of weeks later (April 6, with 13
cases) than the peaks for new cases, hospitalizations
and ventilations. These trends with seven-day moving
averages by first date of confirmed COVID-19, hos-
pitalization, invasive mechanical ventilation treat-
ment and death are shown in Figure 1.
Of the 8569 persons with confirmed COVID-19
in Norway up to June 30, 14 percent were hospital-
ized, 1.7 percent received ventilation treatment and
2.6 percent died. Of those hospitalized, 12 percent
received ventilation treatment and 8.8 percent died.
Of those receiving invasive mechanical ventilation
treatment, 18 percent died. Table I provides the
demographic characteristics of the infected popula-
tion. There were as many men as women among the
confirmed COVID-19 cases, and 16 percent of the
men and 11 percent of the women were hospitalized.
The majority of the infected were below 50 years of
age, and the rates of hospitalization, ventilation treat-
ment and death increased with age. Most of the
infected were born in Norway (71 percent), and the
hospitalization rate is highest among the infected
born in Asia, Africa and Latin-America (19 percent).
The comorbidity proxy shows that 15 percent of the
infected had been hospitalized (inpatient) or received
care in a hospital-based clinic (outpatient) during the
two months before the positive test. Three percent of
the infected were nursing home residents at the time
of the test, of which 47 percent died.
After mutual adjustment for all risk factors in the
generalized linear models (results in Table II), com-
pared to women, men had higher risk ratio (RR) of
hospitalization (RR 1.3; 95% confidence interval
(CI) 1.2–1.5), ventilation treatment (RR 2.8; 95%
CI 1.9–4.1) and death (RR 1.7; 95% CI 1.4–2.1).
Risk of hospitalization and death increased steeply
with age, while the likelihood of ventilation treatment
increased up to age 60 and declined after age 80. The
risk of hospitalization (RR 2.1; 95% CI 1.9–2.4),
ventilation treatment (RR 2.7; 95% CI 1.9–3.8) and
death (RR 2.3; 95% CI 1.5–3.5) was higher if born in
44    K. E. Telle et al.
Table I. Summary statistics for everyone in Norway with confirmed SARS-CoV-2, including percent hospitalized, receiving invasive
mechanical ventilation treatment and dying, by given categories.

Percent in sample Percent hospitalized Percent ventilated Percent dead

Sex
 Female 50 11 1 2
 Male 50 16 3 3
Age groups
  <50 58 6 0 0
 50–59 19 15 2 0
 60–69 11 24 6 2
 70–79 7 37 5 8
 80–89 4 40 2 23
 90+ 1 25 0 55
Place of birth
 Norway 71 13 1 3
  Africa, Asia, Latin-America 21 19 3 1
  Europe, USA, Canada, Oceania 7 10 1 1
 Unknown 2 16 1 7
Comorbidity proxy
  Previous hospitalization last two months 15 24 2 6
  No previous hospitalization last two months 85 12 2 2
Nursing home resident
 Yes 3 11 0 47
 No 97 14 2 1
Number of cases 8569 1172 146 227

Table II.  Risk of hospitalization, invasive mechanical ventilation treatment and death for everyone in Norway with confirmed SARS-CoV-2
(N = 8569) from multivariable generalized linear models including all given risk factors. Risk ratios (RRs) with 95% confidence intervals
(95% CIs).

Hospitalization Ventilationa Death

  RR 95% CI RR 95% CI RR 95% CI

Sex
  Female (reference) 1 (ref) 1 (ref) 1 (ref)
 Male 1.3 1.2–1.5 2.8 1.9–4.1 1.7 1.4–2.1
Age groups
  <50 (reference) 1 (ref) 1 (ref) 1 (ref)
 50–59 2.5 2.1–2.9 5.5 3.2–9.5 9.6 2.0–47.3
 60–69 4.0 3.4–4.7 14.9 9.0–24.6 51.0 11.9–218.7
 70–79 6.8 5.8–7.9 15.3 8.6–27.1 175.6 42.8–719.7
 80–89 9.1 7.6–10.8 9.7 4.2–22.6 374.4 90.7–1544.7
 90+ 9.5 7.1–12.7 0.0 0.0–0.0 607.9 145.5–2540.1
Place of birth
  Norway (reference) 1 (ref) 1 (ref) 1 (ref)
  Africa, Asia, Latin-America 2.1 1.9–2.4 2.7 1.9–3.8 2.3 1.5–3.5
  Europe, USA, Canada, Oceania 1.0 0.8–1.3 1.2 0.6–2.4 0.9 0.4–1.9
 Unknown 0.8 0.6–1.2 0.6 0.2–2.3 0.7 0.4–1.2
Comorbidity
  No (reference) 1 (ref) 1 (ref) 1 (ref)
 Yes 1.6 1.4–1.8 1.1 0.7–1.6 1.3 1.1–1.7
Nursing home resident
  No (reference) 1 (ref) 1 (ref) 1 (ref)
 Yes 0.2 0.2–0.3 0.2 0.0–1.1 4.2 3.1–5.7
Number of observations 8569 8569 8569

aNo patient 90 years old or older received invasive mechanical ventilation treatment.

Africa, Asia or Latin-America than in Norway. 1.3; 95% CI 1.1–1.7), but not with mechanical ven-
Underlying comorbidity was associated with hospi- tilation treatment (RR 1.1; 95% CI 0.7–1.6). Nursing
talization (RR 1.6; 95% CI 1.4–1.8) and death (RR home residents were less likely to be hospitalized (RR
 Risk factors for COVID-19 hospitalizations in Norway   45
0.2; 95% CI 0.2–0.3) and receiving ventilation treat-
ment (RR 0.2; 95% CI 0.0–1.1), but at substantially
higher risk of death (RR 4.2; 95% CI 3.1–5.7) than
non-nursing home residents.
Discussion
Among all confirmed COVID-19 cases in Norway by
the end of June 2020, high age was most strongly
associated with hospital treatment and death. We also
found that male sex and underlying comorbidity pre-
dicted hospitalization and death. These findings are
in line with previous studies [1–3].
Our results suggest that COVID-19 inflicts more
severe disease for Norwegian residents born in Africa,
Asia and Latin-America compared to residents born
in Norway, and that a larger proportion of foreign-
born were hospitalized and received invasive mechan-
ical ventilation treatment.Though the crude mortality
rate was not higher for those born in Asia, Africa and
Latin-America than in Norway, mutual adjustment
for all risk factors revealed that their risk of death was
more than twice as high as for those born in Norway.
One reason for the impact of adjustment is that these
population groups were younger, with an average age
among the infected of 42 compared to 47 for those
born in Norway. The age difference among the hospi-
talized was even larger, with mean age at 53 for those
born in Africa, Asia and Latin-America and at 63 for
those born in Norway. Some previous studies have
also found higher mortality of COVID-19 in certain
ethnic groups in, for example, the UK [2,14], but
results for the risk of ethnic groups in developing
severe COVID-19 are inconsistent across studies
[1,3]. Unfortunately, little is known about the rea-
sons for more severe disease from SARS-CoV-2 for
Norwegians originating in Asia, Africa and Latin-
America. A limitation of our study was lack of more
clinical or socio-economic variables, and it is possible
that our proxy for underlying comorbidity is less fea-
sible for capturing underlying morbidities among
immigrants as they may use health services too little
or too late [4,7]. There is a clear need for better
knowledge about reasons for excess risks among
some immigrant groups – which might be related to,
for example, occupation, income, education, living
conditions, comorbidities, genetic susceptibility,
health literacy, social networks, proficiency in
Norwegian, access to health care and testing – to
combat spread of infections and prepare the health
care system during new waves of disease [4].
We found that almost half of the residents in nurs-
ing homes who became infected, died. Their excess
risk of death remained after mutual control for age
and underlying comorbidity. Residents of nursing
homes in Norway are generally frail, with a mean
time of residency before death of two years [8]. If
infected with SARS-CoV-2, many of them will be
considered too frail to benefit from hospital care or
invasive mechanical ventilation treatment. In our
population, no one above 90 years of age received
invasive mechanical ventilation treatment, and we
find that hospitalization and receipt of invasive
mechanical ventilation treatment is uncommon in
nursing home residents.
Though there are few nursing home residents
compared to the overall population of infected per-
sons, their extremely high mortality rate accounts for
up to 60 percent of all deaths from COVID-19 in
Norway [6]. Thus, studying only patients with
COVID-19 in hospitals [3] is unlikely to provide a
representative picture of risk factors in the general
population with COVID-19. Moreover, although
there are relatively few nursing home residents or
individuals similarly vulnerable to SARS-CoV-2, the
virus infection is commonly severe and small varia-
tions in how and where they receive curative, pallia-
tive and terminal treatment might have considerable
effects on the capacities of the health care system.
The main strength of our study is the complete
coverage of all confirmed COVID-19 cases in
Norway, including coverage of deaths both in and
outside hospitals. Previous studies have typically cov-
ered specific sub-populations or samples where
ascertainment bias has been a serious concern [1–
3,14], or only been able to measure deaths in hospital
[3]. In general, data from the administrative registries
in Norway provide complete information about
health care system contacts, are of high quality and
reliability, and are used extensively in research [15].
Our study is based on the general population, and
our results reflect the real-world situation in the
health care services. The administrative data pro-
vided complete information on everyone, and there is
no recall bias and no loss of follow-up. In particular,
this ensures that we do not miss the large proportion
of COVID-19 deaths occurring in nursing homes,
which has been a concern in related studies (e.g.
[3]). We also capture all immigrants, which has been
a challenge in other studies [2]. However, as our
study is registry based, we lack other important infor-
mation on potential causes and confounders, and in
particular on specific comorbidities [2,3]. Moreover,
like in any study to date on infected individuals, the
testing regime is likely to substantially affect who
were tested and thus confirmed infected. Since not
all infected individuals are tested, the population of
confirmed infected individuals will not cover all
actual cases. During the period covered by our study,
in Norway PCR testing was reserved for health care
46    K. E. Telle et al.
personnel and patients with clear COVID-19 symp-
toms. Thus, our findings may not be representative of
all infected cases, although the number of tests per
confirmed case has been high in Norway compared
to other countries [16]. While ascertainment bias
may be a concern for persons not developing severe
disease, those with severe illness will be captured in
our data as they are hospitalized or live in nursing
homes where control of the disease is crucial. This
may imply that registration is not complete for
younger or healthier individuals, suggesting that
heathier persons are underrepresented in our sample.
Since the number of hospitalized with COVID-19 is
likely to capture everyone, while the number of per-
sons actually having been infected with SARS-CoV-2
might have been larger than we record, the hospitali-
zation rate in our sample is higher than the hospitali-
zation rate of everyone who actually has been infected
with SARS-CoV-2. Thus, the risk of hospitalization,
receipt of invasive mechanical ventilation treatment
and death that we estimate, might be higher than
what we would have estimated if registration had
been complete. If there are differences in testing
practices across population groups – for example, if
immigrants are generally sicker than natives before
they are tested [14] – the excess risks we estimated
for Africans, Asians and Latin-Americans might be
lower than what we found. Better data to analyze and
control for differences in testing is important to fur-
ther improve our knowledge on risk factors for severe
COVID-19.
Conclusions
In all persons with a positive test for SARS-CoV-2 in
Norway by the end of June 2020 (N = 8569), the risk
of hospitalization was higher for the elderly, men and
persons born in Asia, Africa or Latin-America. These
groups were also at higher risk of receiving invasive
mechanical ventilation treatment and dying, but the
mortality risk was especially high for persons of high
age and residents in nursing homes.
Acknowledgements
We would like to thank the Norwegian Directorate of
Health, in particular Director for Health Registries
Olav Isak Sjøflot and his department, for excellent
cooperation in establishing the surveillance register.
We would also like to thank Gutorm Høgåsen,
Ragnhild Tønnessen and Anja Lindman for their
invaluable efforts in the work on the register. The
interpretation and reporting of the data are the sole
responsibility of the authors, and no endorsement by
the register is intended or should be inferred. We
would like to thank the municipal medical officers
and medical microbiology laboratories for reporting
cases and test results to the NIPH. We would also like
to thank everyone at the NIPH who were part of the
outbreak investigation and response team.
Declaration of conflicting interests
The authors have no conflicts of interest to declare.
Funding
The authors received no financial support for the
research, authorship, and/or publication of this
article.
ORCID iDs
Kjetil E. Telle https://orcid.org/0000-0002-7978
-0825
Jon Helgeland https://orcid.org/0000-0002-9348
-7844
Supplemental material
Supplemental material for this article is available
online.
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